9812-191 (SFD)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
I— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
WProfessionals Code, and my License is in full force and effect.
CQ
C) =11 M License # Lie. Class Exp. Date
LLJ
CS Z r— t,D`ate � "f Signature of Contracto, i7 /
CD 0
(. O r i
J U co OWNER -BUILDER DECLARATION
W r— I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ a
N License Law for the following reason:
Z_ (,) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
W
0- Q WORKER'S COMPENSATION DECLARATION
C) 2 Z I hereby affirm under penalty of perjury one of the following declarations:
Lo FZ O () 1 have and will maintain a certificate of consent to self -insure for workers'
X Lu Y= compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
CID Q () (t0 1 have and will maintain workers' compensation insurance, as required by
O UQ Section 3700 of the Labor Code, for the performance of the work for which this
rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
,qt Z Carrier YPolicy No.
Cb 5 Of
YU''Ns J9l »V
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(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
3 subject to the workers' compensation provisions of Se tion 3700 of the Labor
Code1.shal� hwith comply with those provisions.
�D'ate: 2 % r Applicant—-"
c,
Warning: Failure to secure Workers' Compensation coverage i"rt awful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to, the conditions and restrictions set forth on his
4 application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for
inspection purposes.
Signature (Owner/Agent)
d/ ' / _:,- ate
BUILDING PERMIT PERMIT#
01
DATE VALUATION xz4,xa.af1LOT TRACT 28341-2
23 '
ADDRESS is -111, BRAE, .IIi�.MIN JOB SITE
APN 769-iAi0-014
/
OWNER
CONTRACTOR/DESIGNER/ENGINEER
ttf'�!`1��.�i7fC:!' 7"1i,�(?Ae't't<' Q 1`AH'iltr:f'`♦/'\:tA1'i"✓+.
t.,.a:.,J 1A 1,»,N;! a a, ;H 4,,U let), {.1Y Q,.I;1 •\JaJ 4i:a
CllPtll"1ri'174E."i' it [li�'A,f;»'i' C!)1a1"r`1'ti.��C1�ATiti
;./;\1Ja,!}a,; I --.;.r ).,A 1; 1H R...d a/.t?/. IO 1. �.J lV.r.
12865 PO1i I'E DEL MAR, W'1` 200
12,163 VOiNTP .[iis' ..UAR4 SUITE 200
INA, IMAR C:A. 92014-38
0 1JEL MAk CA 92014-38`
('fly}l f-F�"fsiA F;1i(,# 5 -0
USE OF PERMIT
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k?0RC11/1'r T10 302.i1fa !
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PERINU FEE SUR INIARY
MECHANICAL FEE 1131-000-421-000 S79.00
'&L,*C'11UCAL FEL 101-00 0-420-000
d?LtsW1N0 FEr 101 -000 -419 -OW S3l55.?S
S7'RONO }Mc's'('tON ice;. - "WI5IU 110140-2414941(1 VZIZ4 ti
CtiUNN;GI1iC 101 -UQ -423.000 $20.a00
C �
FKFKAiJt\TKURr- FRE "'25-OW-43-.342�V�»a%r37.aq
ARJ' 1N,P03L1C PLACES - iZ:311C 701 -M -255 -OW 5312-04
yl N E';;€`El;;h',
$7,010.76
LESS PRE -PAID FEE
$0.410
I;MAU,, P:FRN11T k.1" DUU NOW
S7,047 76
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R C PT''DATE
BY.
DA J L D
INSPECTOR
J
INSPECTION RECORD
OPERATION a
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap /
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
,Party Wall Firewall
Exterior Lath 'f
AOL
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVA S
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
'
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
I I
CertificatefoOccupancy ,�d�
City of La Quinta
Buffding and Safety Department
This Certificate issued pursuant to the requirements of Section 109 of the Uniform Building Code,
certifying that, at the time of issuance, this structure was in compliance with the various ordinances
of the City regulating building construction or use. For the following:
BUILDING ADDRESS: 55-711 BRAE BURN
Use Classification
Occupancy Group
SINGLE FAMILY DWELLING Bldg. Permit No.: 9812-191
R-3
Type of Construction: VN
Owner of Building: BROOKHELD HOMES SAN DIEGO
Building Official
Land Use Zone: RL
N
Address: 128654 POINTE DEL MAR, STE 200
City: DEL MAR, CA 92014
By: DANIEL P. CRAWFORD JR.
Date: 7/12/2000
POST IN A CONSPICUOUS PLACE